Ross River virus in Melbourne, how did that happen?

aedesnotoscriptus

Health authorities in Victoria have been warning of mosquito-borne Ross River virus for much of the summer. The state is experiencing one of its worst outbreaks of the disease but cases have mostly been across inland regions. Now it’s hit Melbourne. How has this happened?

Ross River virus is the most commonly reported mosquito-borne disease in Australia. There are usually about 5,000 cases across Australia. However, in 2015 there was a major spike in activity with around 9,000 cases reported. It is a common misconception that the disease is only found in northern regions of Australia. I’m often told “I heard the disease is moving south from QLD?” That’s not the case.

The virus is just as much a natural part of the Australian environment as the mosquitoes and the wildlife that maintain transmission cycles.

While there are generally more cases in northern Australia, nowhere is safe. Some of the largest outbreaks have occurred in southern regions of Western Australia, South Australia, Victoria and even Tasmania.

The virus is widespread but is generally associated with rural regions. A driving factor in determining the activity of Ross River virus is that more than just mosquitoes are involved in outbreaks. The virus is maintained in the environment in native wildlife, especially kangaroos and wallabies. Even when and where there are high numbers of mosquitoes, without wildlife, outbreak risk is low. This is the reason why any clusters of locally infected cases in metropolitan regions are typical in areas where there are wetlands, wildlife and mosquitoes occurring together. We’ve seen this on the urban fringe of Sydney and Perth in recent years.

The announcement of locally acquired cases in the suburbs of Frankston and Casey, in Melbourne’s south-east, has taken many by surprise. Should it have?

Victoria is no stranger to mosquitoes and outbreaks of mosquito-borne disease. There are mosquito surveillance and mosquito control programs in place in many regions and historically there have been major outbreaks of mosquito-borne disease. From freshwater flood plains of the inland to the tidally flooded estuarine wetlands of the coast, Victoria has diverse and often abundant mosquitoes. But cases in the metropolitan region are rare.

Victorian mosquitoes are not all bad but over a dozen different mosquito species can spread Ross River virus.

The region where these cases have been identified are in proximity to bushland and wetland areas. There is no doubt plenty of mosquitoes and suitable wildlife too. While this is the first time local transmission has been documented, that doesn’t mean the virus hasn’t circulated in the past, or even that cases may have occurred.

For individuals infected but only suffering mild symptoms, the illness can be easily discounted as nothing more than a mild case of the flu. Without appropriate blood tests, these cases never appear in official statistics. For this reason, many mosquito researchers believe that the number of notified cases across the country is just the tip of the iceberg with many milder infections going diagnosed.

But why in Melbourne now?

It is difficult to know for sure. The two most likely explanations are that either environmental conditions were ideal for mosquitoes and suitable populations of wildlife were present so that the virus was much more active in the local environment than previously. The second explanation is that the virus may have been introduced to the region by a traveller or movement of wildlife. In much the same way Zika virus made its way from SE Asia to South America in the last few years, mosquito-borne viruses move about in people and animals, much less so than mosquitoes themselves (but that isn’t impossible either).

Victoria (as well as inland NSW) is experiencing one of its largest outbreaks of Ross River virus on record following significant flooding of inland regions. With so much activity of the virus in the region, perhaps an infected bird or person travelling to the metropolitan region brought the virus with them. When bitten by local mosquitoes, the virus started circulated among local mosquitoes and wildlife.

Most people infected by Ross River virus are bitten by a mosquito that has previously fed on a kangaroo or wallaby.

Once it’s made its way to metropolitan regions, the virus can be spread from person to person by mosquitoes. Common backyard mosquitoes, especially Aedes notoscriptus, can transmit the virus but as these mosquitoes are not particularly abundant, don’t fly vary far and will just as likely bite animals as humans, they’re unlikely to drive major urban outbreaks of the disease. This mosquito doesn’t pack the same virus-spreading-punch as mosquitoes such as Aedes aegypti that spreads dengue, chikungunya and Zika viruses. Aedes aegypti isn’t in Victoria.

We’re unlikely to see significant spread of Ross River virus across Melbourne but that doesn’t mean Victorians should be complacent. As there is no cure for Ross River virus disease, the best approach is to avoid being infected in the first place. Preventing mosquito bites is the best approach. For my tips and tricks on avoiding mosquito bites see this recent paper in Public Health Research and Practice as well as my article for The Conversation.

Keep an eye on the website of Victoria Health for more information.

 

 

 

 

 

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Lessons from the dengue outbreak in Hawaii

Hawaii_1There are millions of cases of mosquito-borne disease world wide every year so why should we care about a few dozen dengue cases in Hawaii?

Hawaii is no stranger to dengue. There have been outbreaks first dating back to the 1840s. Travellers, including returning residents, are diagnosed with dengue routinely. However, this is the first outbreak of locally-acquired infection since 2011.

As of 17 November 2015, Hawaii Department of Health reports there have been approximately 65 locally acquired cases on Hawaii Island (aka Big Island) including both residents and visitors. Why has this happened and what lessons can be learned from the outbreak?

[update: As of 29 January 2016, there have beenĀ 242 confirmed cases of locally acquired dengue.]

Hawaii provides a fascinating example of the implications (as well as study of spread) of exotic mosquito invasions. With no endemic mosquito species, the pest species found in the Hawaiian islands have all been introduced from elsewhere.

The first mosquito to make it to Hawaii was Culex quinquefasciatus. It is thought to have arrived on a boat from Mexico in the mid 1820s. Interestingly, with no native mosquitoes in Hawaii, there was no word to describe them so they were initially referred to as “singing flies”.

In recent years, it has been the role of Culex quinquefasciatus in the spread of avian malaria that’s been grabbing the headlines. However, in the last few weeks, it has been Aedes aegypti and Aedes albopictus playing a role in the local spread of dengue virus in the spotlight. These two container-inhabiting mosquitoes are the key vectors of dengue viruses (as well as chikungunya, yellow fever and zika viruses) internationally. They’re driving the outbreak now as they have in the past.

There was an outbreak of dengue in 2001 with a total of 122 locally acquired cases. Cases were reported from Maui, Oahu and Kauai with the outbreak thought to have been triggered by travellers from French Polynesia where there was a major outbreak underway at the time. Between 1944 and 2001, the only cases of dengue reported in Hawaii were imported with travelers. Firstly, this highlights how important it is to understand the pathways of infected people, this can help guide assessments of risk.

This was also done from the potential introduction of West Nile virus into Hawaii. Analysing the movement of travelers from regions of endemic mosquito-borne disease has also been used to assess the risk of chikungunya virus introduction to North America.

It was believed that Aedes albopictus played an important role in this 2001 outbreak. This mosquito was not a significant presence in Hawaii until the 1940s. More importantly, Aedes albopictus is not exclusively found in water-holding containers in urban area. Unlike the other vector of dengue viruses, Aedes aegypti, Aedes albopictus is also found in bushland habitats. This makes mosquito control just a little more difficult when authorities need to look beyond the backyard.

Previous dengue outbreaks in Hawaii were thought to have been driven by Aedes aegypti. These outbreaks were significant with an estimated 30,000 cases in the early 1900s followed by approximately 1,500 cases around Honolulu in the period 1943-1944. While not necessarily easy to manage, outbreaks of dengue driven primarily by Aedes aegypti can be strategically targeted by residual insecticide treatments and community education. That education focuses on raising awareness of the public health risks associated with mosquitoes and the need to remove opportunities for mosquitoes to be breeding around dwellings. This model is essentially what is in place to address occasional outbreaks of dengue in Far North Queensland, Australia.

The current outbreak has raised concern in the community. Shelves of stores have been emptied of insecticides and repellents. Community meetings have been held by local authorities to provide information on dengue and address concerns on the Big Island. You can watch some of the meetings here. You can see some of the health promotion (aka “Fight the Bite”) flyers here.

Community engagement is important. An indirect impact of this engagement though is that the total number of confirmed cases of dengue on the Big Island is likely to rise over coming weeks. Not necessarily due to new cases but a greater likelihood that older cases will now be diagnosed through blood tests. Even those who may be suffering a mild illness are likely to be tested for infection and may end up in official statistics.

This dengue outbreak is a reminder to authorities across the world that where suitable mosquitoes are present, a risk of mosquito-borne disease outbreak is possible. The mosquitoes provide the tinder and it only takes the spark of an infected traveler to ignite an outbreak. We saw this in 2014 with the first outbreak of dengue in Japan for 70 years. We’ve seen it this year with local transmission of chikungunya virus in Spain and other outbreaks across Europe.

For Australian authorities, ensuring there are strategic responses in place to address the risk of exotic mosquito introduction, as well as outbreaks of disease, is critical. What this outbreak in Hawaii reminds us is that if Aedes albopictus becomes established in our major cities, it is only a matter of time before we see local outbreaks of dengue, chikungunya or Zika viruses.

What is it like if a loved one comes down with dengue? Check out the channel of YouTube stars Charles Trippy and Allie Wesenberg as they document their brush with mosquito-borne disease during this outbreak.

[Update: Implications for potential Zika virus spread] The recent spread of Zika virus in the Americas has raise concerns by health authorities. In particular, the spread of the virus to North America. What about Hawaii? There has already been one case of microcephaly in Hawaii with a baby born on Oahu to a mother who had been residing in Brazil. The pregnant women was infected in South America, not Hawaii. However, authorities should be on alert as travellers from the Americas, or the Pacific, have the potential to introduce the virus and the mosquitoes currently present in Hawaii spreading dengue viruses are the same that spread Zika virus.